09040152 77 77 77.7777
CITY OF CUPERTINO � � � ;:
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
20613 SCOFIELD DR PREMIER PL BI PERMIT WUE DATE
OWNER'S NAME: INC
A CONTROL NO.
')NE:
T (4 0 8) 9 C 3—818 4 BUILDING PERMIT INFO
ARCHITECTfENGTNEER: C= ELECT PLUMB
MECH
p z LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affi
zrm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Profcasions Code,an my license is C O P PR RE P I P E FM HSE S HT OFF THRU ENTIRE H S E
="c H in full force and cff
z License�1 s Con
Date Y
AaCH1TECl•S D ATItractor
ON
I understand my plans shall be used public records
m
'o,U
L o y Licensed Professional
N OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
K$ which requires a permit to construct.alter,improve,demolish,or repair any structure Valuation
rr"In prior to its issuance,also requires the applicant for such permit to file a signed statement !APN
Ft•Floor Areathatheis licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 • 6650
Y FS (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or.a that he is exempt then from and the basis for the alleged exemption.Any violation of Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars(5500). 3590900'7 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and be structure is not intended or offered for sale(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.if,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law. B&P C for this reason
❑I am exempt under Sec
Owner Date
WORKER'S COMPE ON DECLARATION
I hereby affirm under penal f perjury one of the following declarations:
I have and will maintain a 'frcate of Consent to-if
forworkees Compen-
,.tion,as provided for by tion 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation insurance,as required by Section
duo Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensatio Insurance carrier and Policy m am:
Carrie Policy No.
LATE OF EXEMPTION FRO WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or ICss.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate Of Exemption,you should
become subject to the worker's Compensation provisions of the Labor Code.you must
,J?•_, forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
ice. I hereby af1)rm that there is a construction lending agency for the perfurmamx of
i�> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendces Name
az Lender's Address
U C 1 certify that 1 have mad this application and state that the above information is
LL cormct,l agree to Comply with all city and county ordinances and state laws relating
to
0 U building construction.and hereby authorize representatives of this city to enter upon the
0 W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Zin consequence of the granting of this permit. Date
—+ APPLICA NDERSTANDS AND WILL COM WITH ALL NON-POINT Issued b,t:
SOUR E 0
� • Re-roofs
Sig pplicanucon for Date
HAZARDOUS MATERIALS DISCLOSURE Type of:ZOof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? All roof:.shall be inspected prior to any roofing material being installed.
❑Yesr a If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
tat hazardous air contaminants a�,dcfincd by the Bay Area Air Quality Management all new 1 naterials for inspection.
strict?
❑Yes u
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not cu ntiy have a tenant,that it is my responsibility to notify the occupant of the Date
-qui C is m mel i of teofOccu Signature of Applicant
` All roof coverings to be Class'A•'or better
r o authorize agent Date
CITY OF CUPERTINO
REPIPE/SEWE,R/MAIN SERVICE
CUPEI�TINO PERMIT APP=LICATION FORM
APN# _ Date:
Building Address:
0,45 is N � Phone#:
c ; 25 3 0``
tractor: Phone#:
d Fax#: r'
o act: Phone
Fax #:
Contractor License#:
Cupertino Business License#:
Job Description:
Residential Commercial ❑
Valuation:
Projec ize: xpre s �j Standard Large Major
Green Building: Please complete relevant portio: of the Green Building Checklist& attach it to the
application or if applicable, include in plan set&. the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial rc-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWERMAIN SERVICE
CUPEfZTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standard Commission B ALL PERMIT
Fee TYPES
1 1BSEISMICR Seismic Residential P
1PRSEWER Residential buildixig P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pip(;per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1R-PWS
1PPRSEWG Private Sewage D.sposal System P
1PCESS Cesspool P
1BPWATER Install/alter Watex Pipe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping Systein 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Docum-,ntation Fee B
1BUSLIC Business License
B
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that mist be
shown and referenced on the Project
Plans See below
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (nose) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spe(:.) A-3 2 points
4. B. Fiber Cement Siding, Nate/;�pec.) A-4 s
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points__
5. Tankless W.H., (Note/Spec.) A-2 points
11. A 2500 Gal.Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (NotejSpec.) A-3 1 point
3. Energy Star Refrigerator, Note,Spec.) A-3 1 pcint
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS1 40 points
L�
Plan Review Process Work Book Page-12-Revised 3/25/08